Taildragger,
Please forgive me for mentioning the Privy Council again, but I think there is value in reading this pretty concise summary of the aftermath of the Royal Commission report as it explains why things turned out the way they did:
Andrew McGregor “Accidents, Failures, Mistakes and Leaky Buildings.
(my emphasis)
Mahon also blamed the airline for deliberately conspiring to lie, reflected in his famous ‘litany of lies’ quote. Air New Zealand objected to the Court of Appeal (CA) on the basis of costs. According to historical clauses in the TAIC Act, the CA judged that Mahon overstepped his brief in judging that the Air New Zealand witnesses committed perjury, because it was a crime and could only be judged so in a court of law, not a Royal Commission of Inquiry (Beck 1987). However the Court of Appeal stopped short of faulting Mahon’s technical determinations including the predominant cause of the crash.
Mahon appealed to the Privy Council as a private citizen but the Privy Council not only supported the Court of Appeal, it also cleared the airline of blame without the corresponding rigour of Mahon’s enquiry. This effectively undid much of Mahon’s work and to a layperson, confused the findings. The logic of the Privy Council in clearing the airline of blame remains unclear. The judgement of the Court of Appeal and Privy Council is criticised by Stuart MacFarlane, a retired senior law lecturer, in his book titled The Erebus Papers (1991). According to MacFarlane (1991) and Beck (1987), in order for Mahon to judge between conflicting witnesses, he had to judge that several of them had lied and could not fulfill his mandate without judging so. In their view, this would have been obvious to the alleged liars and the warning that the Court of Appeal and the Privy Council judged should have been given, was unnecessary.
Beck (1987) cites that the main reason to go to appeal was in order to vindicate Air New Zealand of its reputation. Therefore without Mahon’s mandate to apportion blame, Air New Zealand may not have appealed and the investigation process may have concluded with a clearer outcome. It is interesting to note that during the course of Air New Zealand’s final submissions, when it was convenient for them to do so, counsel for the airline invited Mahon to stop short of attributing blame and merely identify the contributing factors. In response, Mahon acknowledged that “the prime purpose of aircraft accident investigation is to secure avoidance of similar accidents in the future, not to identify and apportion culpability or blame for what occurred” and that citing the ten factors was sufficient to achieve this (Mahon, 1981, p. 158). However he advised that his mandate also included the need to “answer the question whether this disaster was caused or contributed to by blameworthy acts or omissions by any person or persons” (Mahon, 1981, p. 158).
The cost of a clouded inquiry and the need to apportion blame was enormous. Following the inquiry, Captain Gordon Vette and Peter Mahon, both leaders and highly respected professionals in their respective fields resigned from their jobs, thus ending their careers. Although Captain Vette continued to implement improvements in international air safety, regrettably Mahon died a few years later. In the minds of many professionals, the judgement of the Privy Council confused the conclusions that Mahon so painstakingly derived and made it difficult for safety professionals to openly promulgate the lessons learnt from the Erebus crash, which ICAO later admitted carried a profound message in preventing organisational accidents in the future.
This is from a well written analysis of how the incremental results of the actions well-meaning people doing what they thought was the right thing at the time, can eventually result in a disaster. Well worth reading
http://www.prosolve.co.nz/accidents.pdf